Compass on COVID: What test for whom and when—lab leaders talk

November 2020—Testing saliva, stocking up, and expanding capacity were top of mind when members of the Compass Group convened by Zoom on Sept. 1 for a second COVID-19-related call with CAP TODAY publisher Bob McGonnagle. Antigen testing, too, came up, and the question to answer there, said Susan Fuhrman, MD, of OhioHealth, is why the test is performed and what will be done with the result.

That and more—testing for patients undergoing treatment for cancer, flu season—were up for discussion. Others on the call were Greg Sossaman, MD, of Ochsner; Lauren Anthony, MD, and Heather Dawson of Allina; Sarah Province and Julie Hess of AdventHealth; James Crawford, MD, PhD, of Northwell; Stan Schofield and Robert Carlson, MD, of MaineHealth; Sterling Bennett, MD, MS, of Intermountain; John Carey, MD, of Henry Ford; and Pamela Murphy, PhD, APRN, of MUSC Health.

The Compass Group is an organization of not-for-profit IDN system lab leaders who collaborate to identify and share best practices and strategies. (For our coverage of their first call with CAP TODAY, see “Compass points chart the pandemic,” September 2020.) Here is what they told us on Sept. 1.

Greg Sossaman, what is the situation in New Orleans? Where is the public testing demand coming from, and how has it changed over the past month or so?
Gregory Sossaman, MD, system chairman and service line leader, pathology and laboratory medicine, Ochsner Health: The pediatrics group developed a whole service line around contracts and services they could provide to schools in the area. Testing could be part of that. We don’t have the capacity now from a PCR perspective, but we’re looking at that as we expand. We’re also looking at providing more rapid testing to employers. People understand the importance of rapid testing and that a test for which it takes a week to get the results isn’t helpful. So there’s been a push for rapid testing, and we’re working on that.

Susan Fuhrman, do you think that the news about Abbott getting approval for its rapid test and the demand for it are making a difference in your life or in the perception of the clinicians and the people in the laboratories?
Susan Fuhrman, MD, president, CORPath, Department of Pathology and Laboratories, OhioHealth Riverside Methodist Hospital, Columbus: The main thing to know is why you’re doing the test and what you will do with the result. That is something we as pathologists have known forever. If you’re testing people to see if they’re contagious today, that’s different from testing someone on whom a procedure will be done. They’re both asymptomatic but it’s different. For the asymptomatic person you’re going to take to the operating room, you want to be sure they don’t have presymptomatic COVID, or even asymptomatic COVID that you then push into symptomatic COVID because of the procedure. That’s one asymptomatic group.

The other is the group that is asymp­tomatic and they’re going to quarantine regardless, so what are you going to do with those results? If you are going to actively contact trace, you want to find the infected contacts rapidly, but testing a contact too soon—within a day or two of exposure—will likely fail to detect virus. The reason you want to find infectious contacts rapidly is so their contacts can be identified and quarantined, and their contacts traced, and so on. These secondary and tertiary positive contacts are also quarantined and tested.

The third asymptomatic group are the folks who probably won’t quarantine unless you tell them they’re positive, so testing them is needed to convince them to quarantine. And then there’s another group for whom you’re going to get a snapshot in time if you test once—were they detectable by PCR or by antigen testing today? Unfortunately, that just tells us if they were infectious today. It doesn’t tell us if they will be tomorrow.

We know that the virus replicates so fast that if you’re positive but below the limit of detection today by an antigen test, the chances are pretty good you will be positive by an antigen test tomorrow. So if you’re going to test people every day or every other day, then using a rapid antigen test is great for seeing if someone is infectious and, if so, quarantining them. Since no negative test is perfect at ruling out infectivity, a negative test does not mean you can throw away your mask and stop social distancing.

I am pleased that the CDC recently published on its website the recommendation that it is unnecessary to retest a positive patient within three months of being positive. I don’t know if that’s going to change with some of the questions about reinfection, but it will reduce unnecessary retesting of those who were recently positive.

We use the Abbott ID Now for our symptomatic patients in our urgent cares and our emergency rooms and freestanding emergency centers because those doctors want a result right away. The central laboratory is performing PCR testing on our asymp­tomatic patients. For our sympto­matic outpatients we mainly use the Abbott Now, depending on volume and availability of reagent for the Abbott assay and for the PCR assays. It’s a juggling act.

Stan Schofield, for this application of rapid tests to, say, junior high school students, how much explanation would you need to provide to the relevant authorities—both medical and in the schools—to get them to understand what the rapid test can do for that population and what it cannot do?

Stan Schofield, president, NorDx, and senior VP, MaineHealth: When I talk to private schools, universities, and colleges, I explain we are testing all of them but we are not doing antigen testing. We’re still with the gold standard, PCR. We’re at Bowdoin College today for 400 students getting swabbed. The Abbott card is made one mile from my office; we inspected their development lab for safety issues in May. It’s all first class. We can’t get a hand on one. The government bought them all, so we don’t know if it’s more sensitive than ID Now. We’re hearing it’s less sensitive, which would make sense given the price point, ease of use, and lack of sophistication without instrument interpretation, but we can’t prove that.

I tell people if you’re going to do these rapid tests you have to do them along the lines of this kind of mentality: Do you want five percent of the population tested with 99 percent accuracy, or do you want 95 percent of the population tested at 85 to 90 percent accuracy and with greater frequency and at lower cost? The rapid tests are a better way to capture pandemic population exposure and incidence rates. But we can’t use that in our facilities because we have to have a COVID-free environment for the surgical cases and diagnostic procedures and nothing less than PCR is acceptable.

The secondary issue is the demand. People have heard incredible stories about antigen testing. We have now started testing in the state of New Hampshire—a state contract for assisted-living facilities that required PCR. They won’t consider antigen testing in the nursing homes for asymptomatic patients.

Will something come close to the gold standard PCR, to maybe a level of being standard silver, good enough with better technology or better cards than what we have today? Yes, there’s a half-dozen companies—I’ve been talking to some—coming out with much lower-cost PCR, and they’ll probably be available by year end.

So there’s going to be more competition and we’ll be looking at that for more point-of-care PCR-level quality in our various organizations. But the FDA is taking a much harder stance on EUA.

The other point-of-care instruments that are coming out are expected this fall, and we’ll have to see what happens to the price point. If you can get an antigen test for $5 that’s 85 percent, would you pay $12 and get PCR at 98? I don’t know.

How is your supply of test kits for your PCR platforms?
Stan Schofield (MaineHealth): We’re using an LDT, so we have been stockpiling master mix and extraction kits. You would think it was Christmas last week when 75,000 pipette tips showed up here finally. At the same time, this week we went back to the gray market for 50,000 universal transport media and swabs out of South Korea. We had nine pallets delivered this week, and two weeks ago we had another nine, so we’re working hard to build up inventory to support our external community and corporate testing. There’s a lot of money there and we’re going to try to capture it while the sun’s shining.

Lauren Anthony, can you give us your reaction to what you’ve heard so far? I’m wondering about the new areas for test demand from businesses and schools and how you’re triaging the different test technologies as you reply to these questions and demands for testing.
Lauren Anthony, MD, system laboratory medical director, Allina Health, Minneapolis: We’re still extremely limited in what we can do on site. We have five platforms going for a total of 220 tests. That’s all we’re doing in-house. We’re collecting more than 2,000 a day and sending the vast majority out. So we’re focusing on trying to add more platforms to get more capacity.

We don’t have funding to stock up. We’re running lean, and we’re having to struggle to bring our case forward to get more equipment and further expand our platforms. We’re still low incidence in Minnesota. [On Oct. 19 the positive rate in the Twin Cities for all tests was six percent.]

We see the antigen test as a way to potentially cut down on PCR in the outpatient world if we can start detecting positives that don’t need PCR, but we’re not sure because it’s going to cost a lot to stock up on that. We’re wondering how others are able to stock up because we’re not. We’re very lean. We can’t bring in molecular platforms that are going to require additional staff to do the pipetting and extractions in a live environment. We’re looking at platforms that aren’t going to require adding staff, and it’s a challenge.

That’s interesting because COVID has been pretty magical for many labs with their administrations in terms of getting what they want and need.
Heather Dawson, VP of laboratory services, Allina Health, Minneapolis: The vendor we used pre-COVID didn’t come through, and when it did, the shipment arrived without COVID reagents. It came with only the STI testing we had originally intended. So with a very small molecular testing department and our recovery work focused on no additional FTEs, it’s been interesting to prove, especially with the large portion of inpatient testing that needs to be done, a return on the cost of all of this. We’re getting there but it’s slow. Because Mayo Clinic is down the road, people expect that we should use Mayo, but from a cost perspective that doesn’t always pan out.

Sarah Province, what’s going on in your neck of the woods?
Sarah Province, director of laboratory operations, AdventHealth, Orlando, Fla.: We are continuing to build capacity. We have consolidated most of the testing at our Orlando campus, and we have capacity now to run about 650 tests a day. We’re using multiple platforms—Luminex, DiaSorin, GenMark, Roche. We’re validating the BD Max now and a second BioMérieux eMag and Luminex MagPix, and a second Eppendorf cycler. We have five Siemens PCR dual systems ready to install. So we’re building capacity. We have pooled testing available on our Luminex Aries.

Finding space for this equipment and the staff needed to run it are our biggest challenges. Our volume has fallen off in the past few weeks, but that is a bit encouraging because we will be better prepared for a surge with school starting and flu season.

We’ll also be able to bring in all of our sendout testing. We send out 200 to 500 samples a day to three different reference labs for ambulatory-type testing. We’ll be able to bring that in-house and all of our inpatient admission screening and any other testing we need the capacity for.

Julie Hess, executive director, laboratory services, Advent­Health, Orlando, Fla.: Our corporate leadership, which is based near the Orlando area, set up a lab governance early on, and they listened to us and the ROIs we presented on what our costs were to send samples out to reference labs and if we could bring them in-house.

We highlighted how patient management would be impacted if we could do these tests locally with a reasonable turnaround time. All of that helped to shape key initiatives by our organization. So they have invested a lot of money—more than $3 million—for us to be able to help manage this.

There has been a lot of aggressive work to get contracts signed and to get negotiated buying power. It has put a strain on our lab team, though, because we are struggling now with the staffing. We could do even more than we are now, but finding people who are qualified, because Florida has a state licensure requirement, is difficult.

We are focused on antigen testing for our community testing. We have a branch that is kind of separate from our laboratory, with our rapid care clinics, and it has embraced the antigen concept. They’re testing symptomatic patients in the community, primarily with the Quidel Sofia platform. We got our hands on the BD Veritor and reagents, and we began to do pilot studies with that.

No one on this call would be surprised to hear the sensitivity was significantly lower than for PCR. Our data seem to suggest that the patients in a rapid care or community clinic setting are going to their doctor within five days as it’s recommended by Quidel in its package insert. But by the time they get to a point where they want to go to an emergency department, they seem to be well past that, so we’re not picking them up as positive on our test.

We’ve talked a lot about what the CDC guidance is about antigen tests in terms of doing surveillance and monitoring a community or population and having that repeat test. We’re exploring what that could look like and if there’s value in it. It could be in our nursing homes as a general surveillance screen. It could be in some of our local prison populations or schools.

And there is also our own patient population. We have a process now for patients on infusion therapy or radiation oncology that they must be retested every 30 days. If we’re going to do frequent repeat testing on a population, even if they’re asymptomatic, I’m wondering if antigen testing would play a role there. I’m concerned about the sensitivity of antigen testing and what decisions we make—how we take care of the patients who are negative if there’s a chance they are positive. But considering the limitation of resources—of people and supplies for PCR—I don’t want to rule that out.

Jim Crawford, what would you say about taking care of this cohort of patients who are on infusion therapy and need to be tested? What strategies are you employing at Northwell?

James Crawford, MD, PhD, professor and chair, Department of Pathology and Laboratory Medicine, and senior VP of laboratory services, Northwell Health, New York: Late April is when these discussions started, which is, with a huge therapeutic as well as survivorship population of cancer patients at Northwell, what should the testing regimen be? Our cancer programming was first in line to sort out what pretreatment testing should be. Once we had calmed down our oncologists in regard to the frequency and urgency of testing relative to when the cancer patients walked in, we were able to assure ourselves as a lab, and our oncology community, that we would be able to test every oncology patient for PCR prior to treatment, but that we did not need two tests 24 hours apart. We had to pull them off that ledge because at the time the CDC and the state of New York were big on two tests 24 hours apart.

The problem we continue to keep an eye on in the setting of high Ct values for what constitutes a positive test is the long residual viral shedding of a positive patient. The whole concept of being asympto­matic and afebrile, however many days or weeks post-resolution of symptoms, has provided assurance that cancer patients can undergo their therapy and don’t necessarily need testing if they’ve had a negative result.

We derive considerable benefit from publications coming out of Memorial Sloan Kettering. Even if a patient is PCR positive but asympto­matic, there is no detrimental effect on response to chemo or radiation therapy or recurrence of symptomatic illness. So it’s a steady-as-she-goes approach.

The other ledge we talked them off of was a PCR test 24 hours before treatment as opposed to 72. Seventy-two hours before turns into 49 hours before if the test sample is obtained late in the day. Seventy-two hours gives us the target two-day turnaround for these high-priority patients.

Where is Northwell’s cancer program now? Is it back to almost normal levels?
Dr. Crawford (Northwell): We are comfortably above normal right now for our surgeries. All chemo and radiation therapy is on full throttle and we were able to clear the backlog of the high-acuity patients through May and into the first half of June so that now we are back to what we hope is a trued-up sustained balance of early diagnosis and intervention. As all of you are experiencing, it’s a different world in which we’re performing our practice. That’s the huge impact of all of this.

Robert Carlson, can you tell us about your experience in this cancer space now?
Robert Carlson, MD, medical director, NorDx, MaineHealth: If you assume that the rate of new cancers is steady and you just delayed the diagnosis and all of a sudden you open back up, you’re going to get that bump of new diagnoses and I suspect that’s the primary cause. As our oncology practices open up, they go through the backlog and we have seen a spike in the diagnostic testing that’s done. I expect it’s going to go back to what it was pre-COVID.

Sterling Bennett, what’s your experience at Intermountain now on any of these topics?

Sterling Bennett, MD, MS, chair, Department of Pathology, Intermountain Healthcare, and medical director, Intermountain Healthcare central laboratory, Salt Lake City: Like many of the other institutions, we are back to full pre-COVID volumes in surgery and other areas. We’ve wrestled with the same questions Susan Fuhrman raised: Who do you need to treat, what are you going to do with the results? And we have triaged the various platforms that we have to different populations of patients and set up different priority levels even within a given platform. That’s all driven by the orders in the EMR. If a person orders COVID, they have to check a number of boxes to identify why they’re ordering the test, and then the order is driven to a particular platform or to a priority within a platform. That’s been a key step for us in being able to use the test ration­ally and optimize the turnaround times for those who need a result more rapidly.

Do you find that the science of testing, for lack of a better phrase, is much better understood today than it was at the end of April?
Dr. Bennett (Intermountain): Yes, by and large it is. Our senior executives are not only very interested now but also have a much better appreciation for the services we provide and for the essential nature of having certain capabilities in-house versus outsourced. That’s one benefit we’ve seen. The other is that physicians, in general, have a better understanding of the concept of predictive value. The testing isn’t simply black or white but needs to consider true positive rates, false-positive rates, prevalence, and then predictive values. So that’s been helpful, and the level of engagement we have with our physicians is the best it’s ever been in terms of test utility.

Greg Sossaman, is your experience similar in there being a greater understanding of what’s involved when you talk about tests and different test technologies?
Dr. Sossaman (Ochsner): Yes, absolutely. My colleague and I are involved in a daily call with our ID physicians and administrative colleagues, and we go through many issues. We learn if there’s any confusion from the front line or from anyone—it comes through that group and we vet these things and get communications back out. It seems like the communication lines are much more open and much tighter than in the past.

Many people are, from what they see in the media and other areas, well informed about testing struggles and what’s going on now, and we get a lot of well-informed questions about testing. Good, hard questions, though there are not a lot of answers. Our cache within the institution has gone up considerably, and we’ve also strengthened ties with our administrative leadership. It’s been great—the anti-commoditization of the laboratory. But, yes, there is more knowledge out there now.

You had mentioned the benefit of introducing rapid tests for businesses, schools, and so on. Is this greater understanding helping you feel better about that type of offering because you feel the players will understand better what you’re offering and not offering by not having a PCR test?
Dr. Sossaman (Ochsner): I think so. For a while when we first introduced the ID Now test there was skepticism about the accuracy. We’ve been able to help people understand the context in which they should use those tests, and that has opened the door to talk about antigen testing with our ID colleagues—where should those tests be performed?

John Carey, what is your reaction to what you’ve heard?

John Carey, MD, Pathology and Laboratory Medicine, Henry Ford Health System, Detroit: I am in line with what the others have said. We’re most intrigued at this point in time with the role of antigen testing. We haven’t implemented it to any extent and we’re debating now between a centralized testing plat­form versus the more rapid point-of-care approach. It depends on what the Abbott platform performance turns out to be. I don’t think we would be interested in going forth with antigen testing if it has sensitivity and specificity similar to early antigen tests. The juice isn’t worth the squeeze.

Like everybody, we’ve been fighting to have sufficient capacity for PCR and are using rapid testing in our community hospitals and in our flagship hospital to facilitate rapid admission and dealing with trauma cases and similar emergencies. Otherwise, we’re continuing to do centralized testing and we’ve been fortunate to get most of that done within 24 hours, 98 or 99 percent of the time.

From what I’m hearing, it appears there’s cause for optimism in the midst of this COVID crisis. Pamela Murphy, is that also your impression? Has the worst passed us now, and is there greater understanding? What is the situation in your area?
Pamela Murphy, PhD, APRN, system administrator, Pathology and Laboratory Medicine Integrated Clinical Center of Excellence, Medical University of South Carolina Health, Charleston: As far as positivity rates now, we’re in a lull, although many are expecting a rise in cases post Labor Day. As far as capacity now, we’re in a fairly good place, but that’s also because our volumes are low. We just got a second Abbott Alinity m, which will get us to about 2,200 to 2,500 internal tests a day. We also have three reference labs now that we can work with, although, as we know from experience, that can change quickly.

We’re getting more Abbott ID Nows in for flu season, where before we were hesitant to adopt those. And we’re working now on saliva testing. We’re looking at several different platforms for saliva testing—a Thermo Fisher assay, the CDC assay, and we’re partnering with the research arm of our academic medical center for this. We’re also looking at the Panther platform as well as the Abbott m2000 and Alinity m for saliva testing in our clinical lab. We’re still in the process of getting enough positive saliva specimens to see if saliva correlates with our NP swabs. But there’s a lot of pressure to validate and implement quickly.

The saliva news has been all over the place and veterans of the laboratory scene like me and Stan Schofield have been hearing about saliva most of our professional careers. Do you agree, Stan?
Stan Schofield (MaineHealth): We’ve been talking about validating it, but saliva is not the simple answer one would think. First, the procedures aren’t automated. Second, we were having problems getting decent saliva collection plastic devices. Third, the staff doesn’t like working with saliva. It’s thick. It’s problematic. Does it clog your liquid handling robots? Do they have to treat it? Did someone not follow the rules and have a chicken sandwich 15 minutes before they provided the sample? We’re struggling with all the relevant items. From a convenience and corporate testing perspective, it would be simple to do universities or colleges. But the other limitations are realistic: the need to validate an assay, to get the robots to handle it without clogging it up, and so on.

Bob Carlson, would you like to add something?
Dr. Carlson (MaineHealth): We looked at one container, a simple plastic one, but we had trouble with people screwing the cap on tight and leaking. We have a kit, which has a wide mouth, but it’s $11 a pop. We looked at another, which has an interesting thing you chew on; it absorbs saliva, and you put it back in and put in the centrifuge. But handling thick specimens with liquid handling systems is a real issue for us, as Stan said.

Susan Fuhrman, what is the view of saliva testing at OhioHealth?
Dr. Fuhrman (OhioHealth): We are also getting a big push to accept saliva testing. We’re bringing up the Thermo Fisher QuantStudio with automated liquid handlers, but they haven’t been delivered yet. I agree with what has been said about the specimen type; that’s the feedback I’m getting from the lab. Those liquid handlers and pipette tips are sensitive to viscous material. That’s going to be a challenge with automated pipetting systems.

Sterling Bennett, what can you tell us about saliva testing at Intermountain?

Dr. Bennett (Intermountain): There’s a lot of interest in saliva largely because it requires less PPE and skill for collection. And as the clinical volumes have returned, the people who were redirected to specimen collection have returned to their primary work.

We’ve done a couple of studies on saliva. For one, we pulled tubes off the shelf and had people drool in them at our collection site. We looked at 466 and had a 93 percent positive percent agreement. For an asympto­matic population that’s probably adequate. Then we got our hands on a commercial kit from Spectrum Solutions and we looked at 318. Interestingly, we had one false-negative, but we detected five additional cases on saliva that weren’t detected by the NP swab.

Saliva looks good from a diagnostic perspective, but we’re not certain we’re going to be able to get adequate supplies. There is a cost to it that may be offset by the reductions in PPE and use of less-skilled staff. But we’re also concerned about the issues of saliva with the automated liquid handling, and our liquid handlers are undergoing validation, so we have not yet tried them on saliva.

Is it fair to say that saliva is not yet ready for prime time in terms of high-volume testing with lab efficiency?
Dr. Bennett (Intermountain): That’s fair to say with automation, but we’re moving quickly toward it with manual processes that are in place today.

Susan Fuhrman, you nodded when I asked if it’s ready for prime time. Would you like to comment?
Dr. Fuhrman (OhioHealth): The issue is high volume. We’re doing 1,500 to 2,000 tests a day now through six platforms. And we do it similarly to what’s done at Intermountain, which is that we’re trying to get the right test for the right patient so it can be interpreted appropriately. What platform it goes to is dictated by the orders and the questions we ask on the orders; then it is sent to the right place. The saliva test is best for screening people when the right PPE isn’t available or you’re not in a hospital setting, et cetera.

If, on the other hand, you have a setup where you’re doing PCR for patients in your emergency room and turning results around within two to three hours, performing them one at a time on a less automated platform, that testing could be performed with a viscous saliva specimen. But it is going to depend on how you’re doing it.

When I look at all these tests and the Yale study, for example, there is no way I could put through the volume I have using that method. That’s kind of a research lab, low-volume method with a lot of manual pipetting. That’s where the rubber meets the road on this.

Robert Carlson, would you like to comment on the same question?

Dr. Carlson (MaineHealth): Susan nailed it. For high-volume, batched processing, using liquid handlers is going to be problematic, but it’s different in the one-off setting with a manual approach. We’re about halfway through our validation on saliva. Our positivity rate is so low that getting paired samples is a slow process. But we’ve seen they compare nicely. We’ve seen better sensitivity on some samples with saliva than some nasal swabs. So it’s not going to be a matter of sensitivity. What’s going to drive it is a matter of handling the sample.

Like Stan Schofield, I’m in contact with people on Wall Street, and in some of the startup biotech companies, they’re excited about T cell activation in COVID. Stan, can you explain what it is that is so exciting to them?
Stan Schofield (MaineHealth): They’re excited because the words T cell activation are new words they never heard before. Six months ago it was rapid testing. Three months ago it was antigen testing. The buzzword in the last six to eight weeks is saliva testing. Now people are talking about T cell activation. They’re asking who knows about it, who’s an expert, who can we call, and I’m in the middle of it all. They’re chasing the latest, greatest, hottest thing so they can try to make a buck.

Lauren Anthony, what are your latest thoughts about the conjunction of COVID and flu?
Dr. Anthony (Allina): We’re expecting that our flu PCR will be greatly affected by the COVID supply issues because the vendors are the same. And if the COVID test also becomes our flu test, it’s going to cause a lot of practice change. We’ve been working with our system expert groups and educating and planning for empirical treatment of flu. The CDC posted that you can treat empirically within 48 hours for low-risk patients and longer than that for high-risk patients. The CDC wants flu out of the picture as much as possible. So we’re educating on empiric treatment and then restricting PCR with decision-support alerts. We need the PCR for high-risk patients and anyone who is admitted to the hospital, and we want to reserve it for those patients.

Sarah Province, what is your outlook on flu and COVID?
Sarah Province (AdventHealth): We’re working through the development of an algorithm that will help triage the cases. We would start with a mini PCR panel that will have flu and SARS-CoV-2. And then from there offer a full respiratory panel that includes SARS-CoV-2 for an ICU-type patient who is symptomatic. Once this algorithm gets built, we’ll be able to know what platforms we’ll run on and how to triage these specimens.

Greg Sossaman, can you give us a recap of this discussion, which is our second round with the Compass Group?
Dr. Sossaman (Ochsner): It’s similar to the first round in that we all have seen the same challenges and struggles. The messages among our institutions seem to be the same again, though with a few different tactics since some labs are being pushed to be as efficient and as innovative as possible—for example, with the use of saliva and pooled testing. We all continue to have similar struggles but also similar optimistic outlooks that we can get through this. More testing can get us through this part of it until we get the vaccine.